Propranolol and Neuro storming.pptx

Investigating the Role of Propranolol
in Paroxysmal Sympathetic
Hyperactivity
Anna Sandler, PharmD Candidate, 2023
1

Learning Objectives
 Explain the epidemiology, pathophysiology, and
clinical features of paroxysmal sympathetic
hyperactivity.
 Recognize current treatments for paroxysmal
sympathetic hyperactivity.
 Synthesize available evidence to determine place in
therapy of propranolol.
 Apply findings for a patient case.
2

Patient case
EG is a 19 year-old male with no significant past medical history who is
brought to Lutheran General Hospital (LGH) with multiple fractures and a
head injury after a high-speed motorcycle accident. Imaging revealed
intraparenchymal, ventricular and subdural hemorrhages on the left side as
well as multiple fractures. The patient underwent immediate interventions
and was admitted to the surgical intensive care unit (SICU).
Imaging
Initial
Interventions
• Seizing upon
arrival
• Hypotensive
• GCS: 5
Physical
Exam/Vitals
3
07.12-15.2022 07.28-29.2022 Future?
• Multiple
hemorrhages
• Scapular,
tibial, fibular
and sacral
fractures
• Intubation
• External
fixation of
tibial/fibular
fractures
• EVD
placement

Patient case-continued
07.12-15.2022 07.28-29.2022 Future?
EG remains intubated and sedated. His medication regimen has changed
due to seizure activity, high heart rate (HR) and elevated temperatures.
Indication Medication Notes
Neuro
management
Levetiracetam
Hydralazine
0.9% NaCl and 3%
NaCl
Levetiracetam: 750 mg BID, Increased from 500
mg BID due to EEG activity
Hydralazine PRN for systolic BP < 140 mmHg
0.9% NaCl continuous infusion
3% NaCl PRN low Na goals
Analgo-
sedation
Fentanyl, propofol Titrated to goal pain/sedation levels
Infection Vancomycin and
Meropenem
Discontinuing with culture results
Sputum grew methicillin- susceptible
Staphylococcus aureus (MSSA)
Prophylaxis Enoxaparin 30 mg SubQ BID
Elevated HR
and temps
Gabapentin
Propranolol
Propranolol increased to 50 mg QID

07.12-15.2022 07.28-29.2022 Future?
Clinical Question
During rounds, a medical resident asks whether EG’s
antibiotics need to be changed due to his persistent elevated
temperatures. The attending explains this is most likely due
to sympathetic hyperactivity and asks you about
propranolol.
What is the evidence behind propranolol in sympathetic
hyperactivity?

Background Lit. Review Back to EG Future studies
Zheng RZ, et al. Front Neurol. 2020;11:81. doi:10.3389/fneur.2020.00081. Accessed August 9, 2022
https://www.ems1.com/traumatic-brain-injury/articles/quick-take-risk-factors-and-interventions-for-patients-with-
tbi-OXdT3hiYO8DN9iTf/, accessed August 7, 2022
Sakai, K.,. Egypt J Neurosurg 37, 7 (2022). Accessed August 9, 2022
6
Paroxysmal Sympathetic Hyperactivity
(PSH)
• Disordered regulation of the autonomic
system.
• Most commonly after severe traumatic
brain injury (TBI)-worse outcomes in
deeper injuries (parenchyma, brainstem).
• Variable incidence rate (8-33%)
• Associated with worse outcomes secondary
to complications, under-recognition, and
misdiagnosis.
More common in
males and
younger patients

Baguley IJ. Med Hypotheses. 2008;70(1):26-35. Accessed Aug 9, 2022
Zheng RZ, et al. Front Neurol. 2020;11:81. Accessed Aug 9, 2022
7
Pathophysiology
• Several theories exist
• Excitatory/inhibitory ratio
(EIR) theory
• Inhibition of descending
and afferent non-noxious
feedback impaired
TBI
Normal PSH
SEI
BEI
BEI
SEI
Non-
noxious
stimuli
Non-
noxious
stimuli
Non-
painful
Painful
Loss of
inhibition

8
Pathophysiology
• Neuroendocrine perspective:
Uncontrollable adrenergic
outflow
• Increased norepinephrine
(NE), dopamine (D),
epinephrine (E) and
adrenocorticotropic hormone
(ACTH)
TBI
Normal PSH
NE
E
D NE
NE
E
E
D
D

Clinical Presentation
• Tachycardia and hypertension
• Tachypnea: respiratory alkalosis
Cardio/pulmonary
• Diaphoresis Dehydration
• Hyperthermia
Temperature
• Rapid onset, duration varies, untreated: 20-30 minutes
• Triggers: ET suctioning, loud noises, repositioning
Episode course
9
UpToDate. https://www.uptodate.com/contents/paroxysmal-sympathetic-
hyperactivity#H395247466. Accessed August 9, 2022

• Based on clinical
symptoms+ diagnosis of
exclusion
• PSH Assessment Measure
(PSHam)
• Clinical Feature Scale+
Diagnosis Likelihood Tool
(DLT)
10
Diagnosis
PSHam
CFS
HR, RR, SBP,
Temp,
Sweating,
Posturing
DLT
Paroxysmal,
temporal
features,
response to
medications
<8= PSH unlikely
8-16= PSH possible
≥17 = PSH probable

11
Knowledge Check
• What are EG’s risk factors for developing PSH?
• What clinical features does EG present with on 7/28-7/29 that
are consistent with PSH?
• What are some differentials that could lead to misdiagnosis of
PSH?

12
Prevent
Abort
Improve long-term
sequelae
Treatment
Goals

13
Current Treatment
•Reducing stimulation
•Physiotherapy
•Sedation
•Room temperature control
Supportive Care
•Clonidine
•Beta Blockers
•Morphine
•Gabapentin
Pharmacologic therapy
Adjuncts:
Bromocriptine,
baclofen,
benzodiazepines

• Non-selective
beta blocker
decreases HR,
myocardial
contractility, BP
• Reduces cerebral
blood flow and
oxygen
consumption
Class/MOA Indications
14
Propranolol
• Arrhythmias
• Migraine
prophylaxis
• Thyroid storm
• Performance
anxiety disorder
No propranolol Propranolol
UpToDate. https://www.uptodate.com/contents/propranolol-drug-
information?search=propranolol&source=panel_search_result&selectedTitle=1~150&usage_
type=panel&kp_tab=drug_general&display_rank=1#F214884. Accessed Aug 10, 2022

Pharmacokinetics Adverse Reactions
• PHS starting dose:
10 mg TID
Dosing/Administration
15
• Onset: 1-2 hours
after PO
• Rapid and
Complete PO
absorption, F~ 0.25
• 4 L/kg distribution
• IR t1/2: 3-6 hrs; ER
8-10 hrs
• Highly lipophilic
• CNS
penetration
Propranolol
• Common
• Diarrhea,
vomiting
• Dizziness, fatigue
• Serious
• Brady-
arrhythmias
• Heart failure,
Heart block,
hypotension
• Bronchospasms

16
Proposed Benefits of Propranolol
Neuro-
protective
Mitigates
hyper
adrenergic
state
Optimizes
brain
perfusion
Brain
volume
control
Mitigates
vasogenic
edema
Koskinen LOD, et al. 2014. Neuroscience 283:245-255. Accessed Aug 12, 2022
Khalili H, et al. 2020 World J Surg. 2020 Jun;44(6):1844-1853. Accessed Aug 11, 2022

Background Lit. review Back to EG Future Studies
Literature Review:
17
Beta Blockers in Critically Ill Patients with
Traumatic Brain Injury: Results from a
Multi-Center, Prospective, Observational
AAST Study
Eric J. Ley, MD; Samuel D. Leonard, BS, Galinos
Barmparas, MD et al. 2018

18
•Evaluate the effects of beta blockers (BBs) on mortality in
TBI patients
Objective
•Multi-center, prospective, observational trial
Design
• Compared patients receiving any BB during admission to
those who did not (BB-)
Intervention
Ley EJ et al. 2018 J Trauma Acute Care Surg. 2018 Feb;84(2):234-244. Accessed

Inclusion Criteria
Exclusion Criteria
19
• >/= 18 y/o
• Blunt TBI w/ CT demonstrating acute TBI
• ICU admission at presentation
• Expired patients in the ED
• > 12 hours since injury if transferring from
outside hospital

20
Data Collection
• Enrolled adult trauma patients with a TBI requiring ICU admission
from January 1, 2015 to January 31, 2017
• Data for patients meeting inclusion criteria collected
• Age, gender
• Mechanism of injury
• Glasgow Comas Scale (GCS) score
• CT head findings and hospital procedures
• Systolic Blood pressure
• Other medications
• Abbreviated Injury Scale (AIS) score and Injury Severity Score
(ISS)
• Beta blocker indication: PSH, HTN, Tachycardia, etc.

Brown PA, et al. JAMA. 2021;325(9):833. doi:10.1001/jama.2021.0669
10%
mortality
rate
2l65
patients 90% power 2% difference
21
Outcomes Statistical Test
• 30-day
mortality
• Length of
hospital stay
• Student’s t test or Mann-Whitney U-Test
• Chi-Square or Fischer’s exact test
• Multivariate logistic regression model+ adjusted
odds ratios (AORs) and 95% CIs
• Kaplan-Meier (KM) curves with Cox-regression
model with adjusted hazard ratios (AHR) and 95%
CIs
• P < 0.05

Results-Baseline Characteristics
Characteristic BB (1120) BB- (1132) P-value
Most
common
BB:
labetalol
IV,
propra-
nolol PO
3rd most
common
Age (mean years) 57 49 < 0.01
Male (%) 70 68 0.29
MVC (%) 21 24 < 0.01
Fall (%) 43 35 <0.01
anticoagulant (%) 24 13 < 0.01
Pre-hospital BB (%) 17 1 < 0.01
GCS </=8 (%) 40 36 0.09
ISS <16 18 34 <0.01
ISS 16-25 36 38 < 0.01
ISS > 25 46 28 < 0.01
SAH 67 60 0.02
IPH 27 25 0.31
22

Results: 30-day mortality
Endpoint BB (n=1120) BB- (n=1132) AOR (95% CI)
30-day
mortality
13.8% 17.7% 0.35 (0.26-
0.47), adjusted
p <0.001
23
Endpoint BB (n=1120) BB- (n=1132) AHR (95% CI)
Adjusted 30-
day mortality
0.42 (0.33-
0.53), adjusted
p < 0.001
NNT
~26

Results: Length of stay
Endpoint BB (n=1120) BB- (n=1132) Adjusted mean
difference (95% CI)
Overall
hospital stay
(mean days +/-
SD)
21 +/- 25 10 +/- 37 8.00 (4.82-11.15);
adjusted p-value <
0.01
24

Results: Lower mortality in propranolol cohort
Endpoint Propranolol
(n=354)
Other BB (n=766) AOR (95% CI)
30-day
mortality
9.3% 15.9% 0.51 (0.31-0.85),
adjusted p =.010
25
NNT ~15

Conclusions
26
Survival
MOA
Non-
randomized
Researchers
• Patients who received beta
blockers after TBI had a lower
unadjusted and adjusted
mortality rate even after
accounting for survival bias
• Propranolol associated with lower
mortality rate than other BBs
Need for randomized controlled studies

Strengths and Weaknesses
27
• Generated KM curves to
account for survival bias
and effect of BB timing
administration
• Profile similar to patient
EG
• Multi-center and large
number of patients
• Observational trial
• Potential for different
results with propensity-
score matching
• Selection bias with
earlier deaths
• Unequal baseline
characteristics
• Lack of long-term follow
up

Literature Review:
28
Role of Early Propranolol in Weaning from
Mechanical Ventilator in Severe Traumatic
Brain Injury Patients
Tamer Habib, Ahmed Sabry, Ahmed El-Beheiry,
Islam Ahmed
Habib, TN et al. 2018 Research and Opinion in Anesthesia and Intensive Care 5.1: 15. Accessed

29
•Investigate whether early, low-dose propranolol after severe
TBI (EPAT) can affect weaning from mechanical
ventilation (MV).
Objective
•Prospective randomized trial conducted in Egypt
Design
• Propranolol 40 mg PO BID (EPAT) versus no BB use (no
EPAT)
• Administered within 24 hours from admission
Intervention

30
Primary Outcome Statistical Test
• Number of days on a MV
• Mann-Whitney U-Test
• Chi-Square or Fischer’s exact test
• P < 0.05

Characteristic EPAT (n= 102) Non-EPAT (n-238) P-value
Age (years) 23-64 24-60 0.061
GSC (mean) 5.12 5.99 0.001
Head AIS score (mean) 3.17 3.64 0.0031
ISS (mean) 17.65 19.74 0.001
SBP (mmHg) (mean) 139.4 140.18 0.579
HR (beats min) (mean) 96.36 87.29 0.0021
Subdural hematoma (%) 31.4 32.8 0.692
Intraventricular
hemorrhage (%)
12.7 9.7 0.822
No significant differences between receipt of mannitol, 3% NaCl,
Craniotomy/craniectomy, or type of brain injury
31

Results: Efficacy
32
Endpoint EPAT (n=102) Non-EPAT
(n=238)
P
Duration of
ventilation (range
days)
4-12 6-16 0.0013
ICU length of stay
(range days)
6-16 8-20 0.003
Hospital stay (range
days)
8-20 10-24 0.005
Mortality [n (%)] 55 (53.92) 125 (52.52) 0.392

Results: Safety and Complications
33
Endpoint EPAT (n=102) Non-EPAT
(n=238)
P
Bradycardia events
(mean)
1.7 4.8 0.06
Hypotensive events
(mean)
0.9 0.7 0.50
ARDS [n (%)] 4 (3.92) 6 (2.52) 0.70
VAP [n (%)] 10 (9.80 20 (8.40) 0.70
DVT [ (n (%)] 1 (0.98) 2 (0.84) 0.09

Conclusions
34
Large studies + mortality
Safety
Length
of stay
MV
duration
Researchers
• EPAT does not increase number or
severity of hypotensive episodes
• EPAT after TBI may be associated with
decreased MV duration and ICU length
of stay
• EPAT does not decrease mortality in the
ICU

35
• Single center and small
sample sizes study limit
conclusions
• Randomized study
• Baseline
characteristics well
balanced
• Good representation
of EG’s head injuries
and closest age range
to EG

Literature Review:
36
Using Propranolol in Traumatic Brain
Injury to Reduce Sympathetic Storm
Phenomenon: A Prospective Randomized
Clinical Trial
Mona Ahmed Ammar, Noha Sayed Husein
Ammar MA, et al. 2018. Saudi J Anaesth. 2018 Oct-Dec;12(4):514-520. Accessed Aug 11, 2022

37
•Evaluate the effects of propranolol on catecholamine levels
and vitals/labs
Objective
•Single-center, randomized, double-blinded, placebo-
controlled trial
Design
• Propranolol 1mg IV versus IV placebo
Intervention

Inclusion Criteria
Exclusion Criteria
38
• Isolated blunt TBI
• 18-60 years old
• GCS 9-12 and normal procalcitonin
• Pre-existing heart disease, MI, craniotomy, pre-
existing cerebral dysfunction, spinal cord injury,
DM, sepsis, severe liver or kidney disease

39
Intervention and Monitoring
• Group B: IV placebo same timeline as group A
• Group A: IV propranolol 1 mg every 6 hours from
admission- for 7 days
• Doses stopped for HR < 60 BPM, MAP < 60 mmHg
Monitoring: Vitals every 2 hours (HR, RR, MAP,
temp), catecholamine levels on admission and day 7

40
• Catecholamine
levels
• Vitals and Labs
• Chi-square tests
• Independent t-test
• Mann-Whitney Test
• P < 0.05

Characteristic Group A (n=30) Group B (n=30) P-value
Age (years) 52 +/- 11.66 55 +/- 12.3 0.238
Sex (male: female) 18:12 16:14 0.602
41
• No statistical differences between the two
groups
• Overall age range: 18-65 years old

Results: Efficacy
42
Endpoint Group A
(n=30)
Group B (n=30) P
NE (pg/mL) day 1 (mean) 523.50 548.00 0.035
NE (pg/mL) day 7 (mean) 206.87 529.33 < 0.001
E (pg/mL) day 1 (mean) 205.37 194.53 0.121
E(pg/mL) day 7 (mean) 69.00 190.73 < 0.001
D(pg/mL) day 1 (mean) 81.63 80.13 0.477
D(pg/mL) day 7 (mean) 32.90 78.00 < 0.001

43
Endpoint Group A
(n=30)
Group B (n=30) P
MABP day 1 (mean) 109.70 109.47 0.896
MABP day 7 (mean) 80.83 90.10 < 0.001
HR day 1 (beats/min,
mean)
106.2 107.00 0.690
HR day 7 (beats/min,
mean)
69.53 90.00 < 0.001
RR day 1 27.73 26.33 0.182
RR day 7 16.03 18.20 < 0.001
Temp day 1 (deg. C) 38.68 38.36 0.065
Temp day 7 (deg. C) 37.16 38.25 < 0.001

Conclusions
44
Support early use of
propranolol
GCS
outcomes
Lower E,
NE, D
levels
Improved
HR, RR,
temp
Researchers
• Propranolol reduced manifestations of
sympathetic storm, with better control of
temperature

45
• Single center study
• Small number of participants
• Exclusion of GCS </= 8 and
many disease states to favor
an overall healthier
population
• Lack of long-term outcomes
• Similar baseline
characteristics w/
few sig. differences
on day 1

Literature Review:
46
Beta-Blocker Therapy In Severe Traumatic
Brain Injury: A Prospective Randomized
Controlled Trial
Hosseinali Khalil, Rebccka Ahl, Shhram Paydar,
et al. 2020

47
•Examine effect of BBs on outcomes in severe intracranial
TBI patients
Objective
•Single-center, non-blinded randomized trial
Design
• Propranolol 20 mg PO Q12H versus placebo
Intervention

Inclusion Criteria
Exclusion Criteria
48
• AIS >/= 3 (severe intracranial injury)
• >/= 18 y/o
• NICU admission
• Pre-existing beta blocker therapy
• Persistent shock (SBP < 100 mmHg or oliguria)
at 24 H after admission
• Transferred from outside hospital

49
• In-hospital mortality
• Extended GCS (GCS-E) on
discharge and 6- month post-
discharge follow-up
20% event
rate
210
patients
80% power
65% RR
reduction with
P < 0.05
• Chi-square or two-sided Fischer’s
exact test
• Student’s t-test or Mann-Whitney
Test
• Poisson regression model
• Adjusted incidence rate ratios
(Adj. IRRs)

50
Intervention and Monitoring
Exclusions from further analysis:
BB+ HR < 50 BPM or SBP < 100 mmHg or refusal to continue 10-day treatment period
Treatment X 10 days
20 mg PO propranolol (BB) Placebo (BB-)
Randomization
Isolated Severe TBI patients

Characteristic BB (-) (n=86) BB (n=68) P-value
Age, mean 37 35 0.60
Epidural hemorrhage
(%)
37.2 38.2 0.90
Subdural hemorrhage
(%)
46.5 36.8 0.22
Subarachnoid
hemorrhage (%)
33.7 26.5 0.33
Intraventricular
hemorrhage
8.1 2.9 0.30
GCS </=8 33.7 25.0 0.24
51

Results: Efficacy
52
Endpoint BB (-) (n=86) BB (n= 68) Adj. IRR
(95% CI)
Mortality [n (%)] 16 (18.6) 3 (4.4) 0.32 (0.1-0.9),
P=0.037
GOS-E at discharge >/= 5
[n (%)]
56 (65.1) 53 (77.9) 1.1 (0.9-1.3),
p= 0.201
GOS-E at 6 months >/= 5
[n (%)]
68 (79.1) 60 (92.3) 1.2 (1.0-1.3),
p= 0.023

Conclusions
53
Routine use of beta blockers
Survival+
outcomes
24 hours
Severe
Isolated
TBI
Researchers
• Propranolol administered at 24 h after
admission in patients with a severe
isolated TBI associated with a significant
decrease in mortality

54
• Single center study
• Unblinded
• Low number of participants
enrolled
• Evaluated longer
term outcomes
• Use of a regression
model to adjust for
covariates
• Good representation
of different disease
states and profile
similar to EG

Summary: Pooling everything together
55
Trial Design Primary findings Limitations Anna’s LOE
(1-4)
Ley et al.
2018
Prospective
observational
Lower adjusted mortality
Propranolol > other BBs
Observational 4
Ammar
2018
Prospective
Randomized
Lower catecholamine
levels on day 7 w/
propranolol
Small n
Single-center
Large exclusion
3
Habib
2018
Prospective
randomized
Shorter duration of MV
with propranolol
Single-center
Unknown
mortality benefits
Older population
2
Khalil
2020
Prospective
Randomized
Significant decrease in
mortality
Single center
Open label
1

Patient EG
EG is a 19 year-old male with no significant past medical history who is
brought to Lutheran General Hospital (LGH) with multiple fractures and a
head injury after a high-speed motorcycle accident. Imaging revealed
intraparenchymal, ventricular and subdural hemorrhages on the left side as
well as multiple fractures. The patient underwent immediate interventions
and was admitted to the surgical intensive care unit (SICU).
Imaging
Initial
Interventions
• Seizing upon
arrival
• Hypotensive
• GCS: 5
Physical
Exam/Vitals
56
• Propranolol 40
mg QID
Beta Blocker
• Multiple
hemorrhages
• Scapular,
tibial, fibular
and sacral
fractures
• Intubation
• External
fixation of
tibial/fibular
fractures
• EVD
placement

EG’s propranolol course
7/22/2022
(Day 11)
7/25/2022
(Day14)
7/27/2022
(Day 16)
Propranolol
20 mg QID
Propranolol
40 mg QID
Propranolol
50 mg QID
Per NG tube

58
Similar to trials Different than trials
• Types of head injury
• GCS score
• Propranolol given after
24 hours since admission
• Younger patient with no
comorbidities
• Patient treated in a
different center with
different practices
• In response to the attending, the evidence behind propranolol/beta
blocker use in PSH 2/2 TBI is mainly based on small single center
studies. Data in injuries similar to EG are promising, but more
studies are needed.

59
• Conduct larger, multi-center sites
• Determine which patients will benefit
• Age
• Comorbidities
• Types of injuries
Future Studies

61
1. Ley EJ, Leonard SD, Barmparas G, et al. Beta blockers in critically ill patients with traumatic brain injury: Results
from a multicenter, prospective, observational American Association for the Surgery of Trauma study. J Trauma Acute
Care Surg. 2018;84(2):234-244. doi:10.1097/TA.0000000000001747
2. Khalili H, Ahl R, Paydar S, et al. Beta-Blocker Therapy in Severe Traumatic Brain Injury: A Prospective
Randomized Controlled Trial. World J Surg. 2020;44(6):1844-1853. doi:10.1007/s00268-020-05391-8
3. Zheng RZ, Lei ZQ, Yang RZ, Huang GH, Zhang GM. Identification and Management of Paroxysmal Sympathetic
Hyperactivity After Traumatic Brain Injury. Front Neurol. 2020;11:81. doi:10.3389/fneur.2020.00081
4. Sakai K, Kitagawa T, Suzuki K, Toh K, Yamamoto J. Paroxysmal sympathetic hyperactivity following acute diffuse
brain swelling due to traumatic brain injury: a case report with good clinical outcome. Egypt J Neurosurg.
2022;37(1):7. doi:10.1186/s41984-022-00146-0
5. Habib T, Sabry A, El-Beheiry A, Ahmed I. Role of early propranolol in weaning from mechanical ventilator in
severe traumatic brain injury patients. Res Opin Anesth Intensive Care. 2018;5(1):15. doi:10.4103/roaic.roaic_58_17
6. Baguley IJ. The excitatory:inhibitory ratio model (EIR model): An integrative explanation of acute autonomic
overactivity syndromes. Med Hypotheses. 2008;70(1):26-35. doi:10.1016/j.mehy.2007.04.037
7. Ammar MA, Hussein NS. Using propranolol in traumatic brain injury to reduce sympathetic storm phenomenon: A
prospective randomized clinical trial. Saudi J Anaesth. 2018;12(4):514-520. doi:10.4103/sja.SJA_33_18
References

Picture Links
• https://www.ems1.com/traumatic-brain-injury/articles/quick-take-risk-factors-
and-interventions-for-patients-with-tbi-OXdT3hiYO8DN9iTf/
• https://www.ems1.com/traumatic-brain-injury/articles/quick-take-risk-factors-
and-interventions-for-patients-with-tbi-OXdT3hiYO8DN9iTf/,
• https://www.google.com/search?q=brain+and+spinal+cord+image+black+and+whi
te&tbm=isch&ved=2ahUKEwjS1_6H5br5AhWrnGoFHfeFC60Q2-
cCegQIABAA&oq
• https://www.topuniversities.com/student-info/health-and-support/exam-
preparation-ten-study-tips
• https://www.topuniversities.com/student-info/health-and-support/exam-
preparation-ten-study-tips
• https://marcguberti.com/2013/11/ways-dominos/
• https://www.chemsrc.com/en/cas/525-66-6_684790.html
62

Appendix
63
hyperactivity#H395247466. Accessed August 9, 2022

Propranolol and Neuro storming.pptx

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